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Inappropriate urinary catheterisation: a review of the prevalence, risk factors and measures to reduce incidence

12 May 2022
Volume 31 · Issue 9


Urinary tract infections (UTIs) comprise the second most common type of healthcare-associated infections, with up to 80% of UTIs caused by indwelling urinary catheters. Current research suggests that the best way to prevent catheter-associated UTIs (CAUTIs) is to reduce unnecessary catheterisation. Few reviews have focused on the prevalence, risk factors and preventive measures for inappropriate catheterisation. This article, consequently, sought to evaluate the current evidence on the prevalence, risk factors and measures that can be taken to prevent inappropriate urinary catheterisation.

Frederic Foley's (1937) design of the self-retaining catheter in 1929 enabled continuous drainage of the bladder and introduced the use of the modern catheter in healthcare practice. Currently, the indwelling catheter is one of the most commonly used medical devices. However, its use can have adverse consequences, such as urinary tract infections (UTIs), urethral injury, urethral stricture and infectious or non-infectious complications (Saint et al, 2018). Due to the process of catheterisation, it can sometimes also lead to less common complications such as a mid-ureteral rupture (Hale et al, 2012; Ishikawa et al, 2014; Sihombing et al, 2021). Complications can extend length of hospital stay, and increase risk of death and healthcare expenditure (Tambyah et al, 2002; Smith et al, 2019).

Evidence shows that most UTIs are linked to catheterisation (Bianco et al, 2018), with catheter-associated UTIs (CAUTIs considered to be the most preventable hospital infection (Umscheid et al, 2011). In 2009, the Infectious Diseases Society of America developed guidelines for the diagnosis, prevention and treatment of CAUTI in adults (Hooton et al, 2010). These advise that urinary catheterisation should be restricted ‘to patients who have clear indications’ and that a catheter should be removed ‘as soon as it is no longer needed’ to reduce the incidence of CAUTI. Indications for indwelling catheterisation include urinary output monitoring, acute urinary retention or bladder outlet obstruction, anticipated prolonged duration of operation, selected surgical procedures, need for intra-operative monitoring of urinary output, patients anticipated to receive large-volume infusions or diuretics during surgery, assistance in healing a sacral pressure ulcer in an incontinent patient, in patients requiring prolonged immobilisation, and in end-of-life care (Gould et al, 2010).

Appropriate catheterisation has been defined as catheter use where the benefits to patient care outweigh the risks, such as CAUTI. This includes the following categories of patients:

  • Those with urinary incontinence where nurses find it difficult to provide skin care, despite the use of other urinary management strategies and resources such as lift teams and mechanical lift devices
  • Patients in whom turning may cause haemodynamic or respiratory instability
  • Those who subject to strict prolonged immobility (eg due to unstable spine or pelvic fractures)
  • Patients subject to strict temporary immobility after a procedure, such as after vascular catheterisation
  • Individuals who have excess weight (>136 kg) from severe oedema or obesity.

Avoiding unnecessary catheterisation and reducing the time a catheter remains in situ are considered the best measures for preventing UTIs. However, even when necessary, many catheterisations are not carried out in strict accordance with indications. This article evaluates current use of urinary catheters, along with the risk factors for, and measure to prevent, inappropriate catheterisation.

Prevalence of inappropriate catheterisation


Internationally, CAUTI is one of the most common healthcare-associated infections (World Health Organization (WHO), 2011) with the main risk factor for UTIs in hospitalised patients identified as indwelling catheterisation (Krieger et al, 1983). Inappropriate catheterisation, including indwelling catheterisation, has been cited as a contributing factor to CAUTI and, over the past 20 years, the incidence of inappropriate catheter use in hospitalised patients has been found to be as high as 40%, with a range of 19–40% (Saint et al, 2000; Munasinghe et al, 2001; Davoodian et al, 2012; Tiwari et al, 2012; Greene et al, 2014a).

Over the past two decades, a number of guidelines on preventing CAUTI and on the appropriate use of urinary catheterisation have been adopted internationally (Gould et al, 2010; Meddings et al, 2015). Although these have emphasised that catheterisation according to indication is an important preventive measure, recent studies have shown no significant improvement, with incidence of inappropriate catheterisation ranging between 20.4% and 35.0% (Laan et al, 2020a; Rasanathan and Wang, 2020; Wooller et al 2018). This may suggest that the prevention and management guidelines have not gained sufficient traction or have not been robustly implemented in clinical practice. According to Meddings and Saint (2011), incidence of inappropriate catheterisation differs at different stages of, what they have termed, ‘the life cycle of the urinary catheter’ (Figure 1). A multicentre monitoring study in the Netherlands (Jansen et al, 2012) supported this assertion, showing that initial catheter placement was inappropriate in 5.2% of cases and late prevalence of inappropriate catheterisation was 7.5%. Research by Kim et al (2017) showed that at 1 week 8.5% cases of catheterisation were inappropriate, at 2 weeks 9.4%, 3 weeks 16.3%, and 4 weeks, 23.1%. As the data show, incidence of inappropriate catheterisation increased with time.

Figure 1. The life cycle of the urinary catheter

Older patients

Between 5% and 10% of elderly residents of long-term care facilities require chronic indwelling catheters for management of urinary voiding (Hooton et al, 2010; Nicolle et al, 2012). However, studies undertaken in the first decade of the 21st century showed that the incidence of inappropriate catheterisation in older people ranged from 4.0% to 54.0%, and this carried a greater risk of death and longer hospital stay (Gokula et al, 2004; Holroyd-Leduc et al, 2005; Hazelett et al, 2006; Holroyd-Leduc et al, 2007). More recent studies also showed no significant improvement in reducing inappropriate catheterisation, with reported incidence ranging from 38.3% to 53.7% (Hu et al, 2015a; 2015b; Hu et al, 2018a). In addition, in terms of ‘the life cycle of the urinary catheter’ (Meddings and Saint, 2011), there was a considerable percentage of inappropriate urinary catheter reinsertions in hospitalised older patients (Hu et al, 2017).

Intensive care unit patients

Patients in intensive care, due to the severity of their condition, lowered immunity and the presence of more medical devices, are a key group affected by CAUTI. Studies have reported the incidence of inappropriate catheterisation in intensive care units (ICU) as 18.5% (Davoodian et al, 2012) and 32.0% (Elpern et al, 2009). More recently, research has shown a higher incidence of inappropriate catheterisation in ICU, with many patients having an indwelling catheter (Kuriyama et al, 2017; 2019); one study reported that the incidence of inappropriate catheterisation was as high as 80.6% (Mota et al, 2019).

Emergency department patients

Indwelling catheterisation is a common medical measure in the emergency department (ED). According to one study, 91% of catheterisation occurs in the ED (Munasinghe et al, 2001); research by Fakih et al (2010), however, found that in 15% of ED cases it was unnecessary, and that only 47% of these cases had a documented physician order. Scott et al (2014) showed that 35% of catheterisations in ED were inappropriate and Schuur et al (2014) found that this was the case in half of cases in EDs, reporting that two-thirds of these could have been avoided. More recently, Hu et al (2018b) showed that urinary catheters were appropriately placed in 75% of ED patients, but in 65.8% of these patients the catheters were then left in situ beyond the time they were required (Hu et al, 2018b).

Inappropriate use of indwelling urinary catheters


Studies have reported a range of reasons for the inappropriate use of indwelling urinary catheters, which would appear to be mainly due to the diversity of research design. In one multicentre prospective observational study (Kim et al, 2017) the main reason cited was for close monitoring of urine volume, with the proportion of inappropriate catheterisation due to this reason increasing gradually over time. Other studies (Kuriyama et al, 2017; 2019) conducted in ICU also reported that monitoring urine volume in non-critical patients was the main cause for inappropriate catheterisation. Even in patients for whom urine volume monitoring was no longer necessary to guide treatment, patients were often left catheterised. This was often because nurses lacked knowledge and understanding on indications for catheterisation, resulting in overuse of the procedure.

Among the available guidelines are the Ann Arbor Criteria (Meddings et al, 2015), which seek to provide guidance on identifying indications for the appropriate use of indwelling urinary catheters. The criteria state that indwelling urinary catheters are appropriate only when hourly urine volumes are required as part of a treatment plan: this is the only method that can provide accurate hourly measurements. Conditions in which this may be necessary include management of haemodynamic instability requiring hourly titrations of medications, acute respiratory failure requiring invasive ventilation with hourly titrations of medical and respiratory therapies, and hourly measurement for urine studies or urine volumes to manage life-threatening, conditions such as critical hyperglycaemia or abnormal levels of electrolytes such as calcium, potassium and sodium. In such cases, monitoring urine volume enables clinicians to determine the dose of therapeutic drugs or infusion volume the patient requires (Meddings et al, 2015).

In addition, research by Elpern et al (2009) showed that incontinence, particularly in women, and concern for skin integrity, were major reasons for inappropriate catheterisation in ICU wards. Similarly, incontinence was also the main reason for inappropriate catheterisation in stroke patients, the purpose being to alleviate patient discomfort or facilitate nursing care (Rasanathan et al, 2020). Other studies (Apisarnthanarak et al, 2007; Greene et al, 2014b) identified that in some hospitals with poor staffing and fewer infection control resources urinary incontinence without obstruction was likely to be used as an indication for catheterisation. Studies with older patients have also shown the main reason for inappropriate catheterisation as ‘convenience of care’ (Hu et al, 2015b). Hu et al (2015a) found that nearly half of inappropriate catheterisation was due to convenience of care rather than indication, for example in patients across all age groups with chronic urinary retention with bladder outlet obstruction. At the stage of catheter reinsertion ‘convenience of care’ is also an important factor that leads to inappropriate catheterisation (Hu et al, 2017).

Other factors for inappropriate catheterisation reported in the literature include:

Research that included exploration of catheterisation at different stages in the catheter life cycle found that physicians were commonly unaware of their patients' stage of catheterisation, and that inappropriate catheters were more often ‘forgotten’ than appropriate ones (Saint et al, 2000). Although nurses and physicians each have their own duties and responsibilities, they share responsibility for catheter placement, care and removal. Nurses were more positive than physicians about current practices and culture regarding the use of indwelling urinary catheters within their institutions (Niederhauser et al, 2018).

Risk factors

Studies on risk factors for inappropriate catheterisation showed that women and older patients were at greatest risk (Apisarnthanarak et al, 2007; Jansen et al, 2012; Hu et al, 2015b). Older patients, those with more comorbidities and those with more serious illness are more likely to have inappropriate catheterisation, which may be related to the devices being used as part of nursing care (Holroyd-Leduc et al, 2005).

Some research showed that inappropriate catheter use at the time of placement was associated with admission to a non-intensive care ward (Jansen et al, 2012). Research by Tiwar et al (2012) identified that the use of multiple catheters and increased duration of catheterisation are risk factors for inappropriate catheterisation. Additional studies suggested other reasons, with the greatest use of urinary catheterisation found in ICU patients (Apisarnthanarak et al (2007) and in surgical patients (Hu et al, 2015b).

Preventive measure

The most effective measure to reduce the incidence of CAUTI is to restrict the use of catheters (Gould et al, 2010; Nicolle et al, 2014). In many cases, catheterisation is simply unnecessary to support treatment. If needed, urine volume can be measured by alternative methods, such as the use of highly absorbent pads, which can be weighed following voiding to determine urine output (Beuscher et al, 2014). Some studies looking at ways to reduce unnecessary catheterisation have reported significant improvements. These interventions are reviewed in the context of Meddings and Saint's (2011) conceptual model: the life cycle of the urinary catheter (Figure 1).

Stage 1. Catheter placement

Some studies described interventions that could be taken at stage 1 (catheter placement) to reduce the incidence of inappropriate urinary catheterisation. The main purpose of any measures taken at this stage is to enhance the health professionals' understanding of catheterisation, increase awareness and knowledge of indications for catheterisation and reduce convenience catheter use.

Effective measures to achieve this included:

  • Providing health professionals with education about catheterisation and an understanding of indications for catheterisation (Gokula et al, 2007; Patrizzi et al, 2009; Fakih et al, 2010; Knoll et al, 2011; Fakih et al, 2012; Jansen et al, 2012; Janzen et al, 2013; Scott et al, 2014; Kuriyama et al, 2019; Laan et al, 2020a)
  • Computerised system redesign to reduce inappropriate use of urinary catheters. (Scott et al, 2014; Knoll et al, 2011). Examples included:
  • Making changes to the computerised nursing template, with nurse asked to select indication for the catheterisation from a dropdown list created from indications on the decision support tool
  • Incorporating a Foley catheter order template into the computerised patient record system. This provided a choice of indication from a drop-down menu or insertion of free text, and included a 72-hour default stop date. When the stop date approached, the system automatically generated an electronic alert, which a Foley catheter team member relayed to the provider currently entering orders for the patient
  • Reducing the convenience of catheter use by, for example:
  • Removing immediate access to catheterisation equipment at the bedside and instead storing insertion kits in a central supply cupboard. This was intended to serve as a reminder for nurses to consider the use of less invasive alternatives, and encouraged them to pause and consider the question: Does this patient really need a Foley catheter?
  • Adding kits for intermittent urinary catheterisation to the supply cupboard as an alternative to indwelling catheterisation. The availability of these kits in the same location as indwelling catheter kits also encouraged nurses to consider the use of the alternative option for obtaining a sterile urine sample (Patrizzi et al, 2009)
  • Instead of inserting a urinary catheter to measure urine output, staff were advised that a scan of a patient's bladder should be made before catheterisation. This would ensure that indwelling catheters were used only in cases when patients urine volumes were greater than 300 ml (Patrizzi et al, 2009).

Stage 2. Catheter care

The main purpose of any measures adopted at this stage is to remove the catheter at an appropriate point in the patient's care pathway to reduce catheterisation time. Effective measures include educating nurses about indications for the use of urinary catheters; nurses who participated in daily rounds were able to assess indications for catheterisation and reminded physicians when catheters needed to be removed (Fakih et al, 2008; Elpern et al, 2009; 2012; Jansen et al, 2012; Kuriyama et al, 2017; 2019; Rasanathan et al, 2020).

Stage 3. Catheter removal

Research showed that the timing of urinary catheter removal was important for reducing complications. According to Ahmed et al (2014), the removal of a urinary catheter 6 hours postoperatively in patients who had had uncomplicated total abdominal hysterectomy appeared more advantageous than either catheter removal immediately after surgery or removal after a period of 24 hours.

The removal of a urinary catheter usually follows the following four steps (Meddings and Saint, 2011):

  • Physician acknowledges the presence of the catheter
  • Physician recognises the catheter is unnecessary
  • Physician writes an order to remove the catheter
  • Nurse removes the catheter in accordance with the physician's decision.

Stage 4. Catheter reinsertion

Intervention measures at this stage are similar to those for the first stage of catheter placement. Research by Brackmann et al (2020) showed that taking a bladder scan of urine volumes can be used to guide catheterisation and thereby reduce unnecessary re-catheterisation. Taking a scan of a patient's bladder will enable staff to determine the level of urine retention and, where the volume is less than 300 ml, there is no indication for the use of an indwelling catheter.


Indwelling catheters are commonly used medical devices, however, indwelling catheterisation can lead to infection, urethral injury, prolonged hospital stay and can also have economic consequences (Tambyah et al, 2002; Smith et al, 2019). Some adverse consequences have been attributed to inappropriate urinary catheterisation. Research has shown that there is a high incidence of inappropriate catheterisation in hospitalised patients in the early stage of their care, with unnecessary catheterisation being undertaken in 19–40% of patients, who have no indications for catheterisation (Krieger et al, 1983; Saint et al, 2000; Munasingheet al, 2001; WHO, 2011; Davoodian et al, 2012; Tiwari et al, 2012; Greene et al, 2014).

Health professionals have recognised the need to implement measures to change the status quo, developing policies and guidelines to reduce the incidence of CAUTIs (Hooton et al, 2010). However, these measures do not seem to have been robustly implemented, with ongoing failures to reduce the rate of inappropriate catheterisation: studies have shown the incidence of inappropriate catheterisation ranging from 20.4% to 35.0%) (Wooller et al, 2018; Laan et al, 2020; Rasanathan et al, 2020). In some patient groups, such as those in ICU, older individuals and those admitted to ED, inappropriate catheterisation is particularly high (Hu et al, 2018a, 2018b; Mota et al, 2019), suggesting that more attention must be paid to determine whether or not the patient's condition has any indications for catheterisation.

To guide treatment it is often necessary to monitor the urinary input/output of patients in ICU. However, it has been shown that this is a major reason for inappropriate catheterisation. The lack of a consensus on which categories of critically ill patients may need to have their urine input and output monitored can result in excessive monitoring of non-critical patients by healthcare staff. To reduce this risk of overmonitoring, the Ann Arbor criteria can be employed to provide guidance on identifying indications for the use of indwelling urinary catheters in critical illness.

Research has shown that there are great differences between the understanding and attitudes of doctors and nurses with regard to restricting the use of catheters (Niederhauser et al, 2018). Guidance on reducing the risk of CAUTI therefore needs to clarify the responsibilities of doctors and nurses in the use and management of catheters. A study by Saint et al (2000) found that doctors often did not know which patients had catheters in situ; they also reported that patients with inappropriate catheterisation were more likely to be forgotten, with catheters remaining in place beyond the time necessary. Another important cause of inappropriate catheterisation is incontinence without obstruction (especially in women) and concerns for sacrum skin integrity. One possible reason for this could be the lack of staff resources, with catheterisation undertaken for the convenience of nursing staff.

There is a higher risk of inappropriate catheterisation in older patients and female patients. Older patients are more likely to have serious conditions and more complications require more care. Research with female patients (Hua et al, 2018a) showed that, in the clinical environment, catheterisation is often used to reduce nursing workloads. Because of their physiological structure, female patients have fewer alternatives to catheterisation compared with male patients. As described above, the lower urinary tract system of males makes it feasible to use alternative devices such as the Texas condom catheter or urinal bedpan (Hu et al, 2018a), consequently putting women at higher risk of undergoing inappropriate catheterisation (Hu et al, 2018b). The topic of whether differences in, what could be termed, convenience catheterisation are due physiological differences between men and women requires further research. There are also some controversies around the risk of inappropriate catheterisation in critically ill patients and surgical patients, as well as an increased risk in non-ICU patients and non-surgical patients.

According to Meddings and Saint's (2011) ‘catheterisation life cycle’ model, preventive measures to reduce the incidence of unnecessary catheterisation include taking action at different stages in the catheter life cycle (by, for example, removing it immediately after surgery). It is therefore imperative to provide health professionals with education about, and raise awareness of, indications for catheterisation, as well as ensuring they are aware of the length of time and for what reasons catheters should remain in situ. In addition, the implementation of workplace measures, such as modifying computer systems to include decision tool templates for catheterisation, with the added benefit of automated alerts, as described above, and reducing overly convenient access to catheterisation kits, have been shown to reduce the incidence of inappropriate catheterisation.

During the period a patient has a catheter in place, indications for continued catheterisation must be evaluated once a day. When there are no indications for an indwelling catheter, nurses should inform the physician, in order that catheter removal can be instigated. Some specialist nurses are able to independently make the decision to remove a catheter, if they do not consider there is indication for catheterisation.

Assessing a patient for catheter replacement should follow the same preventive guidelines as for initial catheter placement, and will require re-evaluation of indications for catheterisation. The need for catheterisation can be determined by a bladder scan, which will measure the volume of urine retention and therefore whether a catheter is indicated. As outlined above, to measure urine output alternatives to catheterisation should be considered, for example, using highly absorbent pads that can be weighed post voiding (Beuscher et al, 2014). The effectiveness of this method in clinical practice needs further investigation because there has been little research into the accuracy of monitoring output using highly absorbent pads. Nonetheless, the outcomes of Beuscher et al's (2014) study demonstrated the feasibility of measuring urinary output in selected acutely ill patients without the need for prolonged use of an indwelling urinary catheter. Reduction in overall catheter use exposed fewer patients to the associated risks of hospital-acquired CAUTI (Beuscher et al, 2014). However, it should be noted that in a busy hospital environment it may not be possible to weigh pads immediately post-voiding, resulting in evaporation that will affect the results. In addition, leaving a pad in place for too long could have adverse effects on a patient's skin management.


Despite the availability of guidelines to minimise inappropriate catheterisation and consequently the risk of CAUTI, failure to adequately adopt them worldwide over the past two decades has meant that the incidence of inappropriate placement remains high. Research shows that inappropriate catheterisation is especially high in older individuals, female patients and those who may be defined as critically ill—with a consequent increased risk of CAUTI. It is clear, however, that adopting comprehensive intervention measures, such as removing a catheter immediately post-surgery or when no longer indicated, and ensuring that catheters are not used as a substitute for the lack of staff resource, are effective in reducing unnecessary catheterisation (Gould et al, 2010; Nicolle et al, 2014).

It is vital that health professionals pay greater attention to inappropriate catheterisation and that they are made aware of and adhere to local policies and international guidelines on the management of indwelling catheterisation. It is also vital to raise awareness among health professionals, including nurses, of inappropriate catheterisation in order to reduce the incidence of CAUTIs, for example through staff education.


  • The incidence of inappropriate placement of catheterisation remains high
  • Inappropriate catheterisation is especially high in older individuals, female patients and those who may be defined as critically ill
  • It is also vital to raise awareness among health professionals, including nurses, of inappropriate catheterisation in order to reduce the incidence of catheter-associated urinary tract infections

CPD reflective questions

  • Reflect on your practice and consider why the rate of inappropriate catheterisation remains high
  • Consider whether we pay sufficient attention to how the adverse effects of inappropriate catheterisation affect patients' health, social and healthcare resources, with related economic effects
  • Think about how we, as health professionals, can make a greater contribution to reducing inappropriate catheterisation